Intervention & Evaluation in a Large Newspaper

1. STOP RSI ! Intervention & Evaluation in a Large Newspaper Presentation to Marconi Research Conference at Marigold 2003 Intervention Research of Computer Use September 13-14, 2003 By Richard P. Wells PhD and Donald C. Cole MD, MSc, FRCP(C) University of Waterloo and Institute for Work & Health on behalf of…

2. Partners Members of the RSI Committee: The Toronto Star: Dianne Forsyth, Dana Greenly, Jeff Hoffman, Vivian Karnilavicius SONG: Sylvia Cowell, Ann Maguire, John Spears, Paul Willis University of Waterloo: Dwayne Van Eerd, Richard Wells York University: Melanie Banina, Anne Moore The Orthopedic Therapy Clinic: Maureen Dwight, Pam Honeyman IWH: Dorcas Beaton, Donald Cole, Sue Ferrier, Sheilah Hogg-Johnson, Carol Kennedy, Hyummi Lee, Michael Manno, Michael Polanyi, Harry Shannon, Peter Subrata, Michael Swift

3. Key Findings: • Reduction in persons with severe/frequent pain • RSI has been controlled but not resolved. • Ergonomic Policy and STOP RSI! Program components are important responses. • Program participation by individuals associated with reduction in risk factors and improvement of health outcomes. • The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is crucial.

4. Outline • Nature, timeline and phases of collaborative research • Intervention areas and specific interventions • Evaluation framework • Exposure assessment • Outcomes • Key messages & directions

5. Collaborative Research: Star-SONG • The Toronto Star - a large newspaper undergoing technological and organizational change. • Southern Ontario Newspaper Guild (SONG) – part of the Communication, Energy & Paper-workers union, long history of health & safety activism. • Two intertwined goals of better musculoskeletal health (particularly upper extremity WMSD) & improved business performance.

6. Collaborative Research: Process • Joint development by workplace parties & research team, approved in collective bargaining, enshrined in ‘Ergonomic Policy’ and called ‘Stop RSI’ programme with goal of reduced WMSD burden. • Ongoing parallel, major moves with new equipment, work re-organization & team training, new software in different departments, attempts to contract out distribution, etc. with goal of improved business performance.

7. Overall Evaluation Program 1998 “Teamed” Group Extensive Repeat Exposure Measurement (subset of n=44) For physical Exposures 1997 Intensive Studies (Phase II) 2001 Cross-sectional Survey Status Quo 1996 Cross-sectional Survey (Phase I) Rest of Workforce N approx 800 Workplace Surveillance Qualitative Documentation & Analysis Secondary Data Linkage

8. Surveys 1996:Cross-sectional Survey (descriptive, analytic) …provided workforce coverage 1997: Suite of Intensive Studies (multiple methods including in-depth interviews, focus groups, surface EMG and additional questionnaire measures) …deepened understanding 2001: Cross-sectional Survey (individually linked) (descriptive, analytic) …measurement of change

9. Evaluation Framework: (i)

10. Evaluation Framework

11. Evaluation Framework

12. Evaluation Framework

13. Assessment Methods Methodologies include: • Interviews • Questionnaires and diaries • Observation and video • Measures of EMG, postures, dimensions • Site administrative data • Compensation system, health care system records linkage

14. Assessment: Workstations (1) Wrist, neck and shoulder postures and dimensions of VDT location on workstation taken, EMG: • Spring/Summer 1999 • Winter 2000 (excluding circulation) • Spring/Summer 2000 (41 participants) 45 Participants (31 female, 14 male) (40/41 new workstations, 3/41> 1 workstations, adjustable keyboard tray 36/41) Did the installation of new workstations improve the postures adopted?

15. Assessment: Muscle Activity (i) How to assess muscle activity in a workplace setting? Muscle activity in a naturalistic setting is determined by: tasks performed, workload, workstation, equipment, technique, task/time organization • Electromyographic signals bilaterally from:Extensor Carpi Ulnaris Brevis (ECRB),Trapezius, recorded using portable EMG system with simultaneous video recording • On/off states of 7 tasks identified while viewing video and simultaneously recorded on computer (Observer Pro 4.0, Noldus Technology, Netherlands): Keying, mousing, phone, deskwork, sitting/standing, at/away from desk, other.

16. Assessment: Muscle Activity (ii) • Two hours of work (on 2 days (am and pm) pre, during, and after interventions). • 30 minute segment analysed; work at desk over-sampled • 33 Participants: Newspaper advertising and finance employees, Clerical, administration, sales, customer accounts and call centre,10 male/ 23 female

17. Mousing Off Assessment: Muscle Activity(iii) • Extracting mousing task EMG from working EMG Mousing On

18. Low static is better High gaps is better Assessment: Muscle Activity

19. Assessment: Muscle Activity

20. Assessment: Muscle Activity Holding Handset (in right hand)

21. Intermediate Outcomes • Shorter term outcomes such as reductions in exposures, that are thought to precede improvements in longer term outcomes such as pain levels and lagging indicators such as injury or lost time from work…

22. Process Indicators: Education • 1998 STOP RSI! training sessions in all departments – 58% reported on 2001 survey • RSI training as part of orientation – 11% of 2001 survey respondents • 90% of 2001 survey respondents felt that The Toronto Star STOP RSI! program had completely to moderately “ensured that all employees are informed about RSI”

23. Intermediate Outcomes: Education Awareness of Causes of RSI

24. Process Indicators: Equipment/ Workspace • Input by RSI Committee during purchasing process • Over 2000 Ergonomic Reports/ Workstation Assessments completed by over 20 trained assessors (56% (459) of 2001 survey respondents) • Among a smaller group, the research team measured workstation dimensions and conducted postural assessments.

25. Feedback Information

26. Feedback Example

27. Feedback Diagrams

28. Feedback Diagrams

29. Feedback Diagrams

30. Intermediate Outcomes : Workstation Dimension Change over Time Gaze Angle vs Monitor Height

31. Intermediate Outcomes : Workstation Dimension Change over Time Mouse Position

32. Intermediate Outcomes : Equipment/ Workspace (ii) Proportion inside preferred location (from questionnaire)

33. Measure Preferred Range Summer 1999 Winter 2000 Summer 2000 Right Shoulder Abduction (°) 0-20 * 57 66 36 Left Shoulder Abduction (°) 0-20 * 67 74 45 Right Shoulder Flexion (°) 0-20 * 47 47 60 Left Shoulder Flexion (°) 0-20 * 45 50 62 Supported Right (%) Yes** 41 79 68 Supported Left (%) Yes** 39 87 79 Intermediate Outcomes : Change in Working Postures over Time Shoulder Posture; Percentage within Preferred Range * If arms are supported on armrests, shoulder flexion and abduction measures that exceed the preferred range represent minimal increases in risk of injury. ** Wrist Support optimum when not typing

34. Intermediate Outcomes : Summary of Equipment/ Workspace/Work Postures Detailed dimension and posture measures • From 1999 to 2001, changes among group of employees (mostly Advertising): • reduced extreme mouse positions (horizontal and vertical) • monitor heights higher but fewer extreme head tilts • fewer monitors displaced to the side and less head rotation

35. Intermediate Outcomes: Job Changes (i) Over past 3 years among 2001 respondents • Different job title/description (32%) • Different tasks in same job (37%) • Broader job scope (29%) • Increased job responsibility (47%) • Changes in immediate supervisor (42%) or co-workers (45%)

36. Intermediate Outcomes: Job Changes (ii) • Increased use of computer (27%) and addition of mouse (36%) • Among users, increased mean hours of use of keyboard (extra 40 min.) and mouse (extra 56 min.) between 1996 & 2001 • Time sitting >2 hours continuously, increased by 9% to 33% of 2001 respondents • Both keyboard use and time sitting were RSI risk factors in 1996

37. Longer Term Outcomes • Among the entire workforce period prevalence of more severe pain (NIOSH case) decreased; • 205/1007 or 20% in 1996 • 127/813 or 16% in 2001 difference p<0.01 NIOSH case: those who have experienced moderate or severe pain and discomfort either once per month or longer than a week over the past year and had no trauma to the area.

38. Longer Term Outcomes: Symptom Level Transitions in 1996-2001 Cohort

39. Longer Term Outcomes: Changes in RSI 1996-2001(ii) Among those with pain • Fewer wrist/hand (- 6%), more shoulder (+7%) and neck (+12%) • Majority in 2001 aggravated by work (yes, 57%; to some extent, 34%) • Persistent problems with work function: Work-DASH (Disability of Arm, Shoulder & Hand) 1996 mean 6.3/100, SD 14.9; 2001 mean7.8, SD15.3 (no significant difference)

40. Longer Term Outcomes: Trends in Musculoskeletal Related Drug Costs

41. Reported Program • Participation: • Training • Workstation Asst. • New equipment ∆ Health Outcome: • Pain intensity (all) • Disability Work-DASH &QuickDASH (sub-set) ∆Potential Risk Factors: • Biomechanical • Psychosocial • Reported Work • Changes: • Computer-related • Job-related Longer Term Outcomes: Analyzing linkages in 1996-2001 cohort (n=433) Confounders/ Effect Modifiers (age, seniority, gender) accounted for

42. Longer Term Outcomes : Predictors of changes in risk factors • Of biomechanical risk factors • multiple kinds of new equipment with likelihood of worse telephone setup (p=0.005) • broader responsibility & scope in job with physical effort (p=0.098) • Of psychosocial risk factors • having a workstation assessment (p=0.062), participation in Stop RSI training (p=0.007), & broader responsibility & scope in job (p=0.032) with decision latitude

43. Longer Term Outcomes : Predictors of changes in health outcomes • In pain intensity • supervisor awareness & concern associated with pain (p=0.161) • keyboard time with pain (p=0.125) • In upper extremity related disability • management support for RSI (p=0.006) & frequency of workers taking part in decisions (p=0.082) with disability (QuickDASH) • physical effort (p=0.119) & decision latitude (p=0.121) with work disability (Work-DASH)

44. Longer Term Outcomes: 2001 Survey Respondents’ Assessment • The STOP RSI! program “promoted continuous improvement in the technology and management practices to control exposure to workplace risk factors that can cause RSI” - 85% completely to moderately agreed • Toronto Star management were supportive in dealing with RSI - 74% agree or strongly agree (vs. 64% in 1996) • Immediate supervisor was aware and concerned - 57% (unchanged from 1996)

45. Future Directions: 2001 Survey Respondents’ Suggestions • Equipment: • mouse wrist rests and longer cords • monitors should be placed at an appropriate distance and height, adjustable to height of person • Workspaces: • all workstations should be assessed/set up for each new employee during 1st week at work and regularly thereafter • working at workstation other than one's own usually uncomfortable - cannot adjust • Social Supports: • awareness sessions with [RSI] “victims” for immediate supervisors

46. Future Directions: Ongoing Tensions Relevant to RSI • Proportion of respondents who disagree that “I can take breaks when I want to” unchanged from 1997 to 2001 (28%) • “…productivity is really important here. You have to be always available on your phone. And all their incentives …[are] based on how much you’re producing.” - manager

47. Ongoing Workplace Directions: • RSI/JH&S committees are continuing training, ergonomic assessments, purchasing guidelines and therapy initiatives • Struggling with: • strengthening management practices supportive of dealing with RSI, particularly at the supervisory level • need to persuade organizational leaders to move “upstream” to influence decisions on new technology, organization of work and design of jobs, as per Ergonomic Policy

48. Key Findings: • Reduction in persons with severe/frequent pain • RSI has been controlled but not resolved. • Ergonomic Policy and STOP RSI! Program components are important responses. • Program participation by individuals associated with reduction in risk factors and improvement of health outcomes. • The RSI and Joint Health & Safety Committees have made a difference, but ongoing corporate support is crucial.

49. Ongoing Research: • Changes in exposure • Company surveillance review • Path modeling for changes in cohort • Integrating the quantitative and qualitative components

50. Supported by: • NIOSH/NIH R010H03708-02 • Centre for VDT & Health Research • Toronto Star • Southern Ontario Newspaper Guild • IWH and indirectly, the Ontario WSIB